A Case of Low Back Pain And Bilateral Hip Osteonecrosis
A 37-year-old man of African-American origin visited a clinic complaining of low back pain (LBP) accompanied by hip pain that he was experiencing since eight months. The severity of pain was varying and often worsened on walking and with rigorous activity. There was no history of trauma or any accident. The patient was a primary teacher and his role involved standing for six to eight hours a day. Though patient was experiencing these symptoms for month, he neither took over-the-counter pain relievers nor approached a clinician for the treatment of LBP.
Patient’s clinical history included childhood onset asthma, and he was hospitalized and treated with corticosteroids for an acute asthma attack around 11 months ago. He was occasionally using the bronchodilator albuterol for asthma symptoms. As a part of his personal habits and history, his smoking and drinking habits (3 -4 alcoholic drinks per week) were prominent.
The most likely diagnosis of this presentation is
- Low back pain/ Hip pain
- Osteonecrosis of the Hip
- Hip fracture
Low back pain (LBP) is a most common ailment affecting work performances, well-being and overall quality of life. The pain may occur as a aching, burning, stabbing, sharp or dull, well-defined, or vague and the severity may range from acute, or subacute to chronic. Underlying pathophysiology may include infection, tumour, osteoporosis, ankylosing spondylitis, fracture, inflammatory process, and radicular syndrome.While the established risk factors are occupational posture, depression, obesity, and aging. Current treatment regimen for LBP involves pain relieving medicines, rehabilition therapies and surgical approach as a last resort. The exact underlying cause of LBP is often difficult to identify thereby making the diagnosis and treatment challenging.1
Nontraumatic osteonecrosis of the femoral head (ONFH) is caused by degradation of bone cells causing subsequent osteoarthritis. It maily affects elderly patients aged between 30 to 40 years. While bilateral hip joints are involved in 75% of patients. Contributing causes of ONFH may include corticosteroids, alcohol abuse, history of trauma, hemoglobinopathy, Gaucher disease, coagulopathies, and other severe ailments.2 Osteonecrosis (ON) of the hip is characterized by insufficient nutrient blood supply to the femoral head causing structural failure of the cortical surface. LBP can also result from concurrent conditions. Moreovre, patients with ON report concomitant pain in the low back, buttock, groin, thigh, and knee. Studies have reported the examples of LBP remotely generated from the hip osteoarthritis who underwent total hip arthroplasty and experienced both a reduction in hip and LBP symptoms. Hip ailments as an underlying cause of LBP may be attributed to the functional interdependence of related regions and thus called as hip-spine syndrome.3
The assessment of clinical and personal history was performed with no significant evidences except a history of trauma affecting several body parts. Physical examination revealed mild stiff-legged limp around the right lower extremity, that was linked to a history of plantar foot surface sensitivity persisting since his frostbite injury. The range of motion was normal and the the lumbar extension-rotation test did not reproduce pain. Neurological tests were normal suggesting absence of neiropathic pain. Lumbar segmental hypomobility and mild paraspinal hypertonicity were reported. Imaging studies indicated a slight left lumbar convexity without significant degenerative alteration in the lumbar spine or sacroiliac joints. Right and left femoral heads revealed a mixed sclerotic pattern. Change in density of the femoral heads and impaction fracture was also noted, which was suggestive of osteonecrosis. Furthermore, an orthopedic examination indicated a diagnosis of bilateral ON that might be linked to a history of corticosteroid use, possibly in combination with a history of alcohol abuse.
Followed by detailed diagnosis, the patient was evaluated for the need of surgical intervention and specialists recommended a bilateral total hip arthroplasty (THA).Chiropractic treatments including palliative care, manipulative therapies, exercises were also employed to relieve the pain. Palliative care included lying down and sitting were reported to be effective.
In the present case, detailed diagnosis was not suggestive of a primary source of LBP originating from low back structures. Radiological studies also did not indicate latent pathology in the lumbar spine. Assessment of the hip were mildly suggestive of several chronic ailments including femoroacetabular impingement and osteoarthritis.
The treatment of patients with LBP requires multiple approaches, an accurate initial diagnosis, close monitoring of complications, and appropriate rehabilitation therapies.1 Differentiating low back from hip pathology can be challenging due to overlapping pain referral patterns. Especially in older patients, degenerative changes makes it more difficult to differentiate pain originating from the low back from pain originating in the hip. A brief assessment of a history and physical evaluation of the low back and hip regions may help in accurate and timely diagnosis.4
At early stage, ONFH can be treated by core decompression with implantation of a tantalum rod that provides bony support by acting as a buttress for the subchondral bone and encouraging bone ingrowth around the rod. However, sometimes patients operated on with decompression may experience more severe pain and restricted walking and had to undergo THA.2 Bone marrow mesenchymal stem cells (BMMSCs) have potential of self-proliferation and multi-potential differentiation, therefore, can be induced to undergo osteogenesis.Therefore, an alternate effective therapy can be introduced.5
It is crucial to perform an evidenced-based diagnostic evaluation for patients with LBP, including clinical and personal history such as smoking and drinking addictions. Osteonecrosis can occur as an accompanying ailment with other conditions such as LBP.
1) Béatrice Duthey. Background Paper 6.24 Low back pain. Update on 2004 Background Paper WHO. March 2013.
2) Lee GW, Park KS, Kim DY, et al. Results of Total Hip Arthroplasty after Core Decompression with Tantalum Rod for Osteonecrosis of the Femoral Head. Clin Orthop Surg. 2016 Mar;8(1):38-44.
3) Minkalis AL, Vining RD. What is the pain source? A case report of a patient with low back pain and bilateral hip osteonecrosis. J Can Chiropr Assoc. 2015 Sep;59(3):300-10.
4) Moore MR, Wilmarth MA, Corkery MB. Differentiating Hip Versus Back Pathology with a Patient Status Post LumbarLaminectomy and Fusion: A Case Study. Orthopaedic Practice. 2014 July; Vol. 26:3-14.
5) Hernigou P, Trousselier M, Roubineau F,et al. Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress. Clin Orthop Surg. 2016 Mar;8(1):1-8.